Urinary incontinence - Diagnosis and treatment

04.11.2014

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[email protected]@yoldemir.com

UrinaryUrinary IncontinenceIncontinence

Tevfik Tevfik YoldemirYoldemir, , MD, BBAMD, BBA

Marmara Marmara UniversityUniversityDepartmentDepartment of of ObstetricsObstetrics andand GynecologyGynecology

DivisionDivision of of ReproductiveReproductive EndocrinologyEndocrinology andand InfertilityInfertility

DefinitionDefinition

•• ““InvoluntaryInvoluntary lossloss of of urine or stool in urine or stool in sufficient amount orsufficient amount or frequency to frequency to constitute a social and/orconstitute a social and/or healthhealth problem.problem.

•• A A heterogeneousheterogeneous condition that ranges in condition that ranges in severity fromseverity from dribbling small amounts of dribbling small amounts of urine tourine to continuouscontinuous urinaryurinaryincontinenceincontinence…”…”


PrevalencePrevalence

•• AAffectsffects up 20% of communityup 20% of community--dwelling dwelling olderolder individualsindividuals

•• Affects up to 50 % of nursing home Affects up to 50 % of nursing home residentsresidents

•• IncreasesIncreases graduallygradually duringduring youthyouth

•• PeaksPeaks aroundaround middlemiddle ageage

•• Steadily increases in the elderlySteadily increases in the elderly


Prevalance of UI among womenEPINCONT Study [n=27.936]

Hannestad et al, J Clin Epidemiol 2003;53:1150-1157

Curr Med Res Opin 2004;20;(6):791-801

Risk Risk factorsfactors


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ReversibleReversible CausesCauses

• • DeleriumDelerium;;dementiadementia

• • InfectionsInfections::urinaryurinary,,respiratoryrespiratory, skin, skin

• • AtrophicAtrophic vaginitisvaginitis, , urethritisurethritis; ; alcoholalcohol ingestioningestion; ; acuteacute illnessillness

• • PharmacologicalPharmacological agentsagents : : diureticsdiuretics, , sedativesedative//hypnoticshypnotics

antianti--cholinergicscholinergics, , calciumcalcium channelchannel blockersblockers antidepressantsantidepressants,,etcetc

• • PsychologicalPsychological causescauses: : depressiondepression, , griefgrief//lossloss

• Endocrine disorders: Hyperglycemia ;excess urine• Endocrine disorders: Hyperglycemia ;excess urine outputoutput; ; excessexcess fluidfluid intakeintake

• Restricted mobility :physical restraints, musculoskeletal• Restricted mobility :physical restraints, musculoskeletaldisordersdisorders

• • StoolStool impactionimpaction; ; chronicchronic [email protected]@yoldemir.com

ClassificationsClassifications of of UrinaryUrinaryIncontinenceIncontinence

• • StressStress

• • UrgeUrge

• • OverflowOverflow

• • FunctionalFunctional

• • MixedMixed componentcomponent ((detrusordetrusor hypercontractabilityhypercontractability andandimpairedimpaired contractioncontraction))

• • ReflexReflex ((spinalspinal cordcord damagedamage))


StressStress

• Leakage with increase in intra• Leakage with increase in intra--abdominalabdominal

pressurepressure

• • UrethralUrethral sphinctersphincter malfunctionmalfunction ((intrinsicintrinsic weaknessweakness) / ) / bladderbladder neckneck hypermobilityhypermobility

• Associated with weakening of pelvic floor• Associated with weakening of pelvic floor musclemuscle

• Loss of small to moderate amount of urine• Loss of small to moderate amount of urine

• No evidence of urgency or • No evidence of urgency or nocturianocturia


UrgeUrge

• • VoidingVoiding dysfunctiondysfunction associatedassociated withwith involuntaryinvoluntary lossloss of of urineurine

• • DetrusorDetrusor overactivityoveractivity

• • UrgencyUrgency

• • FrequencyFrequency

• • NightNight time time voidingvoiding

• Most common in older women• Most common in older women


OverflowOverflow

• Involuntary loss of urine due to distention of the• Involuntary loss of urine due to distention of the

bladderbladder

• Filling occurs to the stretch limit of the bladder• Filling occurs to the stretch limit of the bladder

• Underactive • Underactive detrusordetrusor with/without bladder outletwith/without bladder outlet

obstructionobstruction

• • LargeLarge PVR >400ccPVR >400cc

• • DribblingDribbling, , frequencyfrequency

• • HighHigh ratesrates of of infectionsinfections


Incontinence AssesmentIncontinence Assesment

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Measurement of Bladder Base Measurement of Bladder Base Descent (The QDescent (The Q--tip Test)tip Test)

TreatmentTreatment

• • BehavioralBehavioral ModificationModification

• • PharmacotherapyPharmacotherapy

• • UrethralUrethral InjectionInjection

• • SurgerySurgery

• • DevicesDevices

• • ReferralReferral


BehavioralBehavioral TreatmentTreatment

StressStress IncontinenceIncontinence

1. 1. PatientPatient educationeducation

2. 2. KegelKegel exercisesexercises

3. 3. DietDiet modificationmodification

4. 4. WeightedWeighted vaginalvaginal conescones

5. 5. PessaryPessary

6. Pelvic floor electrical stimulation6. Pelvic floor electrical stimulation

7. 7. WeightWeight reductionsreductions



UrgeUrge IncontinenceIncontinence


2. 2. TimedTimed voidingvoiding

3. 3. HabitHabit trainingtraining

• • urgeurge inhibitioninhibition

• • bladderbladder trainingtraining

4. Avoid caffeine and alcohol intake4. Avoid caffeine and alcohol intake




MixedMixed IncontinenceIncontinence


2. Treat the predominant type2. Treat the predominant type

3. 3. KegelKegel exercisesexercises--81% reduction in urinary81% reduction in urinary

leakageleakage


5. 5. BladderBladder trainingtraining


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OverflowOverflow IncontinenceIncontinence


2. “2. “DoubleDouble voidingvoiding techniquetechnique””


4. 4. AvoidAvoid caffeinecaffeine//alcoholalcohol

5. Barrier product to prevent skin5. Barrier product to prevent skin

breakdownbreakdown



FunctionalFunctional IncontinenceIncontinence


2. 2. EnvironmentEnvironment alterationsalterations

3. 3. GrabGrab barsbars//raisedraised seatsseats

4. 4. CaregiverCaregiver assistanceassistance//educationeducation

5. 5. ScreenScreen forfor depressiondepression//cognitivecognitive impairmentimpairment

6. 6. OccupationalOccupational //PhysicalPhysical therapytherapy


PharmacologicalPharmacological TreatmentTreatment

• • AnticholinergicsAnticholinergics==detrusordetrusor underactivityunderactivity, , maymay causecauseretentionretention

• • CholinergicsCholinergics==detrusordetrusor overactivityoveractivity, , maymay causecause frequencyfrequency

• • AlphaAlpha agonistsagonists==outletoutlet overactivityoveractivity, , maymay causecause retentionretention

• • AlphaAlpha blockersblockers==outletoutlet underactivityunderactivity, , maymay causecause stressstressincontinenceincontinence


AnticholinergicsAnticholinergics

• • DarifenacinDarifenacin ((EnablexEnablex))

• • OxybutyninOxybutynin ((UropanUropan XL)XL)

• • SolifenacinSolifenacin ((VesicareVesicare))

• • TolterodineTolterodine ((DetrusitolDetrusitol))

• • TrospiumTrospium ((SancturaSanctura))

• • FlavoxateFlavoxate ((UrispasUrispas))


AlphaAlpha AgonistsAgonists

• • PhenylpropanolaminePhenylpropanolamine hydrochloridehydrochloride--nono

longer marketed in U.S. (longer marketed in U.S. (IntracerebralIntracerebral

hemorrhagehemorrhage))

• • PseudoephedrinePseudoephedrine ((SudafedSudafed))

• • MidodrineMidodrine ((ProamatineProamatine))


AlphaAlpha BlockersBlockers

• • AlfuzosinAlfuzosin ((UroxatralUroxatral))

• • DoxazosinDoxazosin ((CarduraCardura))

• • TamsulosinTamsulosin ((FlomaxFlomax))

• • TerazosinTerazosin ((HytrinHytrin))


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PhysiologyPhysiology of of StressStressIncontinenceIncontinence

1. Urethral sphincter fails to protect against1. Urethral sphincter fails to protect against

lossloss of of urineurine

–– IntrinsicIntrinsic weaknessweakness

–– FailureFailure toto contractcontract

2. 2. UrethralUrethral hypermobilityhypermobility

3. 3. CoexistCoexist togethertogether


PharmacologicalPharmacological TreatmentTreatment ofofStressStress IncontinenceIncontinence1. 1. PhenylpropanolaminePhenylpropanolamine hydrochloridehydrochloride //pseudoephedrinepseudoephedrine

//midodrinemidodrine

• • ReductionReduction in in padpad changeschanges

• • ReductionReduction in in incontinenceincontinence episodesepisodes

• • ImprovementImprovement in in subjectivesubjective symptomssymptoms

2. 2. DuloxetineDuloxetine ((CymbaltaCymbalta))

• • InhibitorInhibitor of of serotoninserotonin//norepinephrinenorepinephrine reuptakereuptake

• Increases serotonin/• Increases serotonin/norepinephrinenorepinephrine levels in the sacrallevels in the sacral

spinalspinal cordcord

• Increased contraction of urethral sphincters during urine• Increased contraction of urethral sphincters during urine

storage phase of storage phase of micturitionmicturition [email protected]@yoldemir.com

PhysiologyPhysiology & & PharmacologicalPharmacologicalTreatmentTreatment forfor OveractiveOveractive BladderBladder

1. 1. NeurogenicNeurogenic

–– CauseCause--enhancedenhanced bladderbladder CC--fiber fiber sensorysensory inputinput

–– AbnormalAbnormal atropineatropine--resistantresistant parasympatheticparasympathetic transmissiontransmission

–– AcetylcholineAcetylcholine mediatesmediates detrusordetrusor contractioncontraction

2. 2. AnticholinergicAnticholinergic versusversus placeboplacebo controlcontrol

–– 41% experienced a cure or improvement in urinary 41% experienced a cure or improvement in urinary incontinence,incontinence, improvement in leakage episodes/24 hours, improvement in leakage episodes/24 hours, number of voids in 24number of voids in 24 hours, volume at first contractionhours, volume at first contraction


DistributionDistribution//FunctionFunction of of MuscarinicMuscarinicReceptorsReceptors ThroughoutThroughout thethe BodyBody

• M1:• M1:CerebralCerebral cortexcortex, , hippocampushippocampus, , salivarysalivary glandsglands, , eyeeye--memorymemory//cognitioncognition

• M2:• M2:BladderBladder, , HeartHeart, , eyeeye, , hippocampushippocampus--heartheart rate/rate/teartearsecretionsecretion

• M3:• M3:BladderBladder,,salivarysalivary glandsglands, , eyeeye, , brainbrain--bladderbladder

contractioncontraction/ / bowelbowel motilitymotility

• M4:• M4:BasalBasal forebrainforebrain, , salivarysalivary glandsglands

• M5:• M5:SubstaniaSubstania nigranigra, , eyeeye--visualvisual accommodationaccommodation


MuscarinicMuscarinic ReceptorsReceptors AntagonistsAntagonists

• • DetrusorDetrusor contraction contraction ––mediated by M3mediated by M3 muscarinicmuscarinicreceptorsreceptors

• • MainstayMainstay of of treatmenttreatment

• Choose an agent that is selective for the• Choose an agent that is selective for the bladderbladder


SurgicalSurgical TreatmentTreatment

IndicationsIndications::

–– FailedFailed nonsurgicalnonsurgical managementmanagement

–– Unable to tolerate side effects of medicationsUnable to tolerate side effects of medications

–– MoreMore definitivedefinitive therapytherapy


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BurchBurch Burch + PDRBurch + PDR

TVT TVT ––11


TVT TVT --22


TVT TVT --33


TVT TVT --44


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TOT TOT --11


TOT TOT --22


PessariesPessaries

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Urinary incontinence - Diagnosis and treatment